Championing Healthcare Integration for Major Transformation – For Patients and the System
Jodeme Goldhar’s passion has helped healthcare organizations break out of their siloes to work together for a common goal – enhancing the care experience and outcomes for their most vulnerable clients.
She has had strong support from the (mostly female) leadership team at Toronto Central Community Care Access Centre (TC CCAC) particularly CEO Stacey Daub. Jodeme’s position as Lead for Health System Integration for Complex Populations and Primary Care has allowed her to facilitate a true partnership between organizations to develop and implement ICCP, a program which smooths transitions (for example, between home and hospital) and forms one care team around each client. Each team is quarterbacked by a TC CCAC care coordinator who communicates with team members and works with the client’s family doctor to develop a coordinated care plan – based on the priorities of the client and family caregivers.
ICCP began as a pilot project focussed on frail seniors, the 1% of patients who use 30% of healthcare resources. It brought together an unprecedented variety of healthcare organizations within the city of Toronto.
Jodeme often prefers to put the spotlight on these partners and the transformation they’ve achieved: Toronto Central LHIN, Toronto EMS; Mount Sinai Hospital, St. Michael’s Hospital, Toronto East General Hospital, St. Joseph’s Health Centre; Woodgreen and St. Christopher House representing the Community Support Sector; Regional Geriatric Program; Bridgepoint Health representing the Rehab and Complex Continuing Care Sector; primary care (Family Health Teams and solo doctors); social services and others.
ICCP has been remarkably successful in improving the satisfaction and comfort of clients and their family members while reducing their need for emergency medical services, hospitalizations and long-term care. The program was always seen as an incubator, a place to learn about how functional integration could work most effectively. The lessons learned are now being expanded to patients beyond the ‘1%.’
Jodeme holds Masters Degrees in both Social Work and Health Science, Health Policy, Management & Evaluation. Her experience as a social worker influenced her conviction that the best place to start effective change was by asking the client and family caregiver what was important to them, and that was the first task in ICCP.
From the beginning, Jodeme has championed some of her guiding principles, including:
- Encourage simple solutions while waiting to develop complex ones
- Invest in building relationships
- Agree to start working together differently immediately
- Drive Change from experience
- Empower front line staff: Inspire creativity, remove barriers
- Share planning, decision making & accountability across the team
Based on the success of ICCP, Jodeme had the opportunity in 2012 to become Planning Lead for Health Links, an initiative of the Ontario Government based in part on the success of ICCP. In this role, Jodeme is supporting relationship building between family doctors and community care services to support doctors with their most complex and clients, and provide better support and care to these vulnerable individuals and their family caregivers.
ICCP is changing lives, and changing the health system across Ontario – and beyond.